There are two kinds of hernias through the hiatus of the diaphragm: sliding hernias where the GE junction slides into the chest and paraesophageal hernias where the GE junction stays in place but the stomach herniated alongside it. This type of hernia is is a true hernia because it includes a peritoneal layer. These hernias account for only 1% of midline hernias but are significant because the stomach can then become twisted and ischemic causing perforation of ulcers called Cameron’s ulcers. . A patient with a paraesophageal hernia with chest pain is a medical emergency and ischemia of the stomach must be ruled out.

In the sliding type of hernia, gastroesophageal reflux is the most common complaint. In the paraesophageal hernia, they can be asymptomatic or develop, vomiting, chest pain, anemia and Barrett’s esophagus.

Our patient became symptomatic with vomiting and a five port approach to repair his hernia with a laparoscopic repair. Gastric reduction, excision of the sac, esophageal lengthening by wedge gastroplasty creating a “neoesophagus”, crural repair and Nissen fundoplication were done. The patient recovered without incident.

The congenital diaphragmatic hernias that appear on the ER boards are Bochdalek and Morgagni. The Bochdalek is most common on the posterior left side of the diaphragm ( Bochdalek is back to remember it easily) and the Morgagni is on the anterior right. Case courtesy of Keith Naunheim.